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    Sunday, August 14, 2005

    Releasing the Black Butterflies*: It's all too easy sometimes to stand in our pharmaceutical golden age and look back on the past in chagrin at what once passed as the gold standard of medical therapeutics. The idea that tobacco could cure asthma is unthinkable now. So is the idea that sitting in the sun or cutting away a patient's ribs would cure tuberculosis. But there is one procedure that stands out among all others as a brutal reminder of how badly amuck the medical profession can go in its quest for a cure - the frontal lobotomy.

    Today, we consider the procedure - which involves the surgical destruction of selected areas of the frontal lobe of the brain - a malignant stain on the history of medicine, and neuropsychiatry in particular. We think of Jack Nicholson's post-lobotomy stupor in One Flew Over the Cuckoo's Nest, or Jessica Lange as a permanently sedated lobotomized Frances Farmer (who apparently never did have a lobotomy), and think what arrogant monsters these doctors were to foist such barbarity on such helpless patients. There is even a serious movement to take back the Nobel prize of the lobotomy's inventor - Portuguese physician (and politician) Egas Moniz.

    But, as author Jack El-Hai discovered in researching his book The Lobotomist, a biography of America's chief lobotomy enthusiast, it was not such a clearly evil thing back in its day. Before the advent of the drugs that made chemical lobotomies possible, a day in the life of the mentally ill was closer to the Snake Pit than to the Cuckoo's Nest. It was in this environment that Dr. Walter Freeman practiced.

    Freeman began his career in psychiatry in 1924 at St. Elizabeth's hospital in Washington, D.C. which at the time house 4300 psychiatric patients. By the 1940's, when lobotomy was its peak popularity, the hospital had 7,000 patients. Turn those number over in your mind for a minute. That's the size of a small town. You'd be hard pressed today to find any hospital with that many patients of any type, let alone purely psychiatric. The Cleveland Clinic, with its sprawling campus and worldwide outreach, has a meager 956 beds, total. Today, St. Elizabeth's houses 600 patients.

    In those days, the hospitalized mentally ill weren't just people who were considering or threatening suicide. They were tough cases. Patients in the end-stages of neurosyphillis and alcoholic dementia, with schizophrenia and severe depression - the violent, the psychotic, the catatonic. They were, in short, the hopeless. And what was it the doctors and nurses who were their keepers could do for them? Nothing, except stand by watching helplessly - and hopelessly.

    Freudian theory and psychoanalysis was on the rise, but it held no promise for these patients. A patient has to have at least some capacity for insight to respond to talk therapy. Besides, syphillis doesn't respond to analysis. And so it was that doctors turned to shocking therapies - insulin shock therapy, Metrazol shock therapy, electroconvulsive shock therapy, and of course, most shocking of all - the lobotomy.

    Of all the shock therapies lobotomy was the most barbaric - the most invasive, the most irreversible, the most dangerous. Walter Freeman had an uphill struggle to convince his colleagues that the lobotomy was a viable therapeutic alternative. Many of his colleagues questioned the ethics of tampering with a patient's personality. Famed neurologist Loyal Davis (father of Nancy Reagan), called it "lazy, mutiliating, and criminal." Religious leaders fretted that it removed the soul's spirituality. The American Medical Association denounced it, as did the head of St. Elizabeth's hospital, William White, who never did allow Freeman to operate on any of the hospital's patients, calling it "spurious and irresponsible."

    Walter Freeman, however, was a natural showman - and an expert manipulator of the popular media. A few months after performing his first lobotomy in 1936, Freeman presented the case to the annual meeting of the Southern Medical Association. He made sure, however, that newspaper reporters would be there, by inviting the science writer for a Washington newspaper to witness a lobotomy and its before and after effects on patients. His timing was perfect. The paper ran a glowing account of lobotomy and its ability to turn "uncontrollable sorrow to normal resignation." The next day, Freeman's presentation in Baltimore was notable for the number of reporters attending it. He staged another public relations coup a year later at the annual meeting of the American Medical Association. His floor exhibit highlighting the procedure not only included photographic case studies but a lobotomized monkey. The display got him a glowing article in the New York Times which was picked up by newspapers worldwide. Freeman capitalized on the publicity with public lectures, just as entertaining as his professional displays. By 1942 he and his neurosurgeon partner, James Watts, published a book about lobotomy. Largely ignored by professional journals, it was widely reviewed in the popular press, including the The New York Times which described it as "more exciting than most novels." By that time Freeman was a clear darling of science reporters. Despite the misgivings of many of his professional colleagues, his theories got favorable - and uncritical publicity - in newspaper and magazine articles across the country. The Associated Press called lobotomy a "personality rejuvinator," with as much risk as a tooth extraction. The tide of public opinion was a strong one and by the late 1940's, the medical profession embraced lobotomy, too. It become a popular alternative, not only for the desparately and hopelessly mentally ill, but for the merely difficult to manage as well. Freeman became bolder. He advocated the procedure for chronic pain, and championed its use as an office procedure that could be performed even by a psychiatrist rather than a neurosurgeon. At least one contemporary lamented the influence the popular press had on the spread of lobotomy, and hoped that in the future treatments would first be proven safe and effective before being touted in the popular press. Over a half century later, we can still hope.

    Even at the peak of its popularity, there were those who sensed - correctly - that the procedure's purpose was not to alleve the suffering of patients, but to relieve the suffering of doctors, nurses, and family members. Dr. White, in explaining why he would never allow Freeman to perform the operation at St. Elizabeth's, noted that "relatives not infrequently desire the death of patients in hospitals. I do not mean that they do this consciously, although I have no doubt that they do in many cases, but that they do so in the back of their heads there is no question, because these sick people cause them a tremendous amount of trouble." The director of the New York State Psychiatric Institute wondered if "perhaps all it accomplishes is to make things more convenient for the people who have to nurse them." Lobotomy often left patients docile and vacant, and in general much less troublesome. It was a desparate solution for desparate people. Too bad those desparate people weren't necessarily the patients.

    We're no better today at separating our own suffering from the suffering of patients. Witness the trend toward euthanizing the mentally incapacitated and severely handicapped infants. But fortunately for the mentally ill, they've been spared our tender mercies. Some would argue that the civil rights movement had some impact - helping us to recognize that the rights of man apply to all humanity, not just a select few. But the truth is that the introduction of Thorazine, a powerful anti-psychotic, and its chemical descendants probably did more to bring an end to lobotomy than any lofty ideals human rights ever did.
    We are not so much better, after all, than doctors of ages past.

    *A reference to a French phrase for depression which translates to "I have black butterflies every day," and which inspired Freeman's cover art for his popular book - a skull with black butterflies flying out of its lobotomy holes.
     

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